An image problem
Women are between a rock and a hard place, if you will excuse the expression, when trying to decide when, and how often, to have a screening mammogram.
Start at 40? Or 50? Once a year? Every two years?
Breast cancer strikes one in seven women. How do you know whether you are at risk?
And when did they take breast self-exams off the to-do list?
Do mammograms save lives? Or do they find tumors that would never have required treatment, putting women through the misery of surgery, chemotherapy or radiation?
What's a woman to do? Ask the experts. We turned to three local doctors to answer five questions about mammograms.
Dr. Kathy Helzlsouer, an expert in breast cancer research and risk assessment and director of the Prevention and Research Center at Baltimore's Mercy Medical Center.
Dr. Cecilia Brennecke, head of radiology at the Johns Hopkins Breast Center at Green Spring Station, who specializes in a variety of breast imaging techniques.
Dr. Stacey Keen of Advanced Radiology of Maryland, a breast cancer survivor and radiologist who wrote a book about her experience and who focuses on breast imaging.
Question: Why did health officials stop recommending that women examine our own breasts for lumps or changes every month?
Helzlsouer: It is still true that some women find a breast lump that was not picked up on mammography or find it even before they start regular screening. However, several studies have looked at whether regular breast self-examination ultimately reduces death from breast cancer and they have not found a benefit.
Women doing breast examination were able to detect more breast lumps than the women who were not taught careful breast self-examination. But for the most part, those breast lumps were not cancer. Indeed, many women find their breast lumps when showering and washing not as part of a systematic breast examination. In addition, some women were not able to master the technique, or felt guilty if they failed to do it or anxious when they did.
Women can still do their own breast exams; it is always good to know your body. And you can ask your health care provider how to do it properly if you are unsure.
Q: When should I start getting mammograms? And where should I go? How do I know if a radiology center is good at breast cancer screenings?
Brennecke: Nothing has changed. Start at 40 and come back every year. You can consider stopping at the age of 80. A breast center is a good idea, and there are a lot of them in Baltimore. Radiologists are focused on breast imaging at these centers, and surgeons are focused on breast imaging.
All of the centers in the United States must now be accredited by the Food and Drug Administration, and they are very strictly controlled. But the one thing they don't assess is this: "Is the radiologist doing a good job interpreting the exams?"
The best way to determined this is to know whether the radiologist does a high number of readings. It does help to do a lot of something. The requirement is 960 over a two-year period. I think the FDA minimum is very low. [Brennecke reads about 7,000 images a year.]
Keen: People are going to accuse me of being prejudiced, but a screening mammogram picked up my cancer in my 40s, and it saved my life.
You can ask the facility how many readings their radiologists do each year. [Dr. Keen reads about 5,000 a year.] And if you need to find a center near you, you can go to mammographysaveslives.org. Just plug in your ZIP code.
You should also ask how many false negatives a facility has. We are obligated to give that information to the accrediting body, and facilities are often proud of that rate. [A false negative rate of 10 percent to 15 percent is considered normal.] Mammography is the best screening tool we have, but it is not perfect.
Q: Is it better to get a digital mammogram or does the old film screening do just as well? What about MRIs and ultrasounds?
Brennecke: Digital is best. To me, there is just no comparison. Digital equipment costs 10 times as much, but I don't see anyone hanging on to film screening anymore. It is particularly good for young women, who typically have dense breast material. If you are at high risk, you should be getting an MRI in addition to a mammogram, not instead of it. It does not take the place of a mammogram.
For those women who are at increased risk but who don't fall into the very high-risk category, we like ultrasound. We can pick up an additional three cancers a year in dense breasts.
Keen: You'd assume that digital would be better than film screening, but a study in the New England Journal of Medicine looked at that and found that digital was a little bit more sensitive in detecting breast cancer in women younger than 50 with dense breasts and who were pre- or peri- menopausal. But in women with fattier breasts, film screening did just as well.
Q: Should I have my previous mammograms with me? Does that help the radiologist? And how long should I wait for results?
Brennecke: Patients would do themselves a favor if they brought everything they have with them. Everything is on discs now, and it is cheap and easy to get. Reading a mammogram is not easy. People say it is like looking for a stop sign, but it is like looking for a green stop sign in the trees.
A reasonable amount of time is two weeks, but we try to do it in a much shorter interval. And we try to get you back in within a month. [The law requires that patients, as well as their primary care physicians, receive a report within 30 days.]
Keen: One of my teachers once said to me, "Nothing makes you smarter than old films." That has stayed with me.
We love comparing to prior studies. Everyone is a little asymmetrical. If you are stable over many years, we know it is a benign finding and we are not going to be asking you for additional views. If it has been there since 1985, we can relax.
If it is a screening mammogram, the radiologist will look at it the next day. If it is a diagnostic mammogram [meaning something is suspected], we read them on the spot.
[Both doctors agree that a patient can ask to have a screening mammogram read right away.]
Q: How do I know if I am at high risk for breast cancer? And what do I do?
Helzlsouer: The first thing you need to know is what are the risk factors for breast cancer. Factors include family history of breast cancer remember to consider both your mother's and father's side of the family. Other factors include starting your menstrual periods very young; having a child later in life; a history of breast biopsies, especially those that show atypical cells; and having dense breast tissue.
The Breast Cancer Risk Assessment Tool (cancer.gov/bcrisktool) can help you determine your risk. This is a good tool to use if you do not have a strong family history either on your mother's or father's side of the family. In addition, you should ask your health care provider to do a cancer risk assessment.
If you do have a strong family history (several generations with breast and/or ovarian cancer, especially if breast cancer occurred before the age of 50) then you should see a cancer genetic counselor. Genetic testing may help to sort out your true risk and help determine what you should do for screening and prevention.
Women in high-risk groups should begin screening 10 years earlier than the earliest age onset of breast cancer [in their history].
Women with dense breasts should also talk to their doctor and radiologist to find out if adding ultrasound or MRIs to their regular screening would help.
There are medicines approved for breast cancer risk reduction in women in the higher-risk group raloxifene for women after menopause and tamoxifen for women older than age 35.
The other things you can do are exercise regularly, manage your weight and limit your alcohol intake to less than one drink a day on average two to three drinks per week at most.